The new year, indeed the new millennium and the new age in health care are now upon us. Futurists — those experts who avoid the trenches so they can hold their heads above everyone else — are having a heyday predicting the changes we will face. Too often their heyday feels more like my Mayday! Consultants who profit from predicting and preparing for constant change are warning us that we need their charts to navigate “the white waters ahead in the modern health care marketplace.”

Years in the wilderness have taught seasoned canoeists the first rule of steering through the rapids: Put your faith in your paddle and your paddle in the water. Family practice is the product of currents both swift and strong. The paddler in the bow looks downstream for rocks, eddies and snags. The navigator's position is in the stern, where one can best see the shape of the river and steer the boat.

As we navigate the future let us look deeply into the water, judge the currents and see our own reflection there. Instead of forecasting what will change, let us recognize the things that will stay the same. Let us identify elements basic to health, illness and caring relationships that will likely form the foundation for any future. Family medicine is based upon continuity. We must presume a continuity in needs and values that will carry our mission forward into the future we will share with our patients and our communities.

KEY POINTS:

Patients will continue to place a high premium on the human aspects of medicine despite emerging technologies and advances in health care.

Family physicians can best prepare for the next century by staying true to the values that have guided them in the past.

Practicing quality family medicine is fundamental to the type of future our patients expect and deserve.

People in need seek comfort, help and direction. All societies have created special roles for healers, complete with their own rituals, language and symbols of authority. People turn to them in times of illness, distress and life transitions. In our society, these universal traditions are combined with the modern magic of science and technology. Much is asked of today's doctors by patients and their families, and much is given. Add the demands of insurers, employers, regulators and lawyers. Yet still more is necessary to provide appropriate health care to all those in need.

A doctor's touch may be even more potent than his or her time, treatments or technology. Hard disks, software and the Internet will certainly help empower patients and their doctors. We must not, however, allow the enhancements to displace the essence of the doctor-patient relationship. Information is only one part of communication. The needs of our patients go beyond answers to FAQs.

A comforting hand establishes a closer connection than can a telephone, computer or modem. The power of observation works best at close range. In short, it's e-mail for detail, but visit or miss it. Unless the pressures of production squeeze out the time it takes, face-to-face interaction with our patients is our most powerful diagnostic and therapeutic resource.

Primary care is the comprehensive management of unselected patients with undifferentiated problems. Unfortunately, those without front-line primary care experience do not fully understand the challenges of family practice: the variety, the complexity and the uncertainty. We have seen ample demonstration that primary care delivers equal or superior patient outcomes, at a lower total cost, with greater patient satisfaction, over a wider variety of conditions than other types of medical service.

To the managed care industry, however, primary care is just a commodity to buy on a per-member-per-month contract from the cheapest provider network. There are plenty of people eager to sell themselves as providers of primary care: nurses and naturopaths, underemployed surgeons and overconfident optometrists, chiropractors, chiropodists and kinesiologists. Yet who among them understands that primary care calls for the broadest education and most seasoned judgment?

Primary care defined

“Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”

Source: Institute of Medicine, Committee on the Future of Primary Care. Primary Care: America's Health in a New Era. Washington, DC: National Academy Press, 1996.

Family medicine is patient-centered, family-oriented, evidence-based primary care that is delivered in the context of the family and community. Only the family physician provides care that fully meets the Institute of Medicine definition of primary care [see “Primary care defined”]. Family medicine delivers added value that goes beyond algorithms and between protocols. The savings are sometimes hard to quantify with the clumsy information systems built for billing, but most patients recognize the added dimension offered by family practice, and many communities depend upon it.

Health is more than the absence of disease, and care is more than the provision of diagnostic and treatment services. Comfort, confidence and communication contribute to improved outcomes and higher satisfaction, for both the patient and the doctor. Employers whip their employees back and forth between bidding HMOs in a war for the cheapest care. Health plans compete by selling professionals at the deepest discount. Regulators count HEDIS (Health Plan Employer and Data Information Set) measures; everyone counts dollars. With whom does the patient count? None of this translates directly into the well-being of the individual patient. Family practice is based on relationships that count. The physician who integrates knowledge and wisdom, nurtures important relationships and understands the needs of the whole patient will be the healer we need.

Physicians are a valuable resource: talented, trained and tried in the trenches. We have a long tradition of achievement, dedication and professionalism and can generally be trusted to do the right thing. Now, many of us have taken on the role of protecting our patients from much that is going wrong in the health industry melee. Doctors understand incentives, play the rules and — while our energy lasts —exploit the Byzantine complexities of the “system,” often for the benefit of the patient. Instead of griping about doctors gaming the system, cost control managers should work with us to design systems, align incentives and provide effective, efficient care to the patient. Doctors are not the problem, disease is.

Bigger and bigger bucks are being made off medical products and services. Investor-owned businesses exist to benefit their stockholders; service to customers is only a means to that self-serving end. These managers make money the old-fashioned way: they sock it to the sick. “White water” must refer to their cash flow. Profiteers will scarf at the health care trough just as long as they can make more money selling our services than selling widgets. Systems do not provide care; people do. Contracts do not create commitments; relationships do.

The connection between employment, insurance and access to health services is an American accident, but the connection between socioeconomic status and health status is no accident. The medical-industrial complex is a threat to patients, our profession and the public health. Making money by denying care, discarding workers and downloading risk is destroying the infrastructure of health care in our communities. Patients who fall through the holes left in the safety net will not be saved by the golden parachutes the CEOs enjoy for themselves. Sooner rather than later our society must face our obligation to guarantee universal access to health care. Securing this commitment is the greatest challenge we face as a nation and is the greatest opportunity for professionals and patients to work together for the common good.

It is easy to worry these days. Business barons like to belittle our background as office-based general practitioners in the community. They call what we do a dying cottage industry. Real doctors, they say, are subspecialists in metropolitan medical centers. Real patients have insurance and require procedures. Health system analysts who deal with printouts rather than patients declare that services can only be provided efficiently by corporate systems organized according to proprietary standards.

Family practice has long promoted outcomes, teams and accountability. There is also enduring value in the more intangible aspects of what we offer: communication, continuity and comprehensive care. We must recognize it in ourselves and renew our commitment to deliver it daily. Family medicine research often deals with cost-effectiveness analysis and population outcome measures, but we must remember that not everything that counts can be counted (and not everything that can be counted counts). The biggest benefits and costs are almost always the hardest to measure. They are the human treasures and tragedies: life, death, fear, joy, trust, pain, reassurance, healing and renewal. These are the parts of people that family doctors work with every day.

Today's businesses buy and sell both doctors and patients not to relieve pain but to return profits. Personally, I feel that I provided more compassionate, comprehensive care as a cottage worker than I do as an interchangeable cog in the engine of medical industry. I believe that when rationality returns to American health care our values will be valued. Perhaps it is time we modernize the classic motto, “Illegitiminon carborundum” to read, “Insurance industrinon carborundum.” Your adversary might be the patient's insurance plan or your employer. In the future it might be your own union. Sometimes it is our own competitive instinct. We cannot let the “wheels of progress” grind down our professionalism, our pride or our patient care performance.

Family medicine can lead future reforms in health care if we mind the milestones that mark the road that has carried us safely so far. Let us remember our heritage. That cottage may not impress the builder or the banker, but it has served well for generations: It stood in the community; it had a hearth and it was a home.

Any future health care system worth being part of will be based on what is best about the family physician. Declare your values in what you do. Demonstrate the value of what you do. Recall the essence of why you became a family doctor and treat each patient with a generous dose of that special elixir. It may not be on the health plan formulary, but it is a trusted treatment with a long record of safety and effectiveness. Prepare the future for yourself and for your patients. Demand that the system provide you the opportunity to be the best family doctor you can be. Family medicine is much more than primary care. Be more than a provider. Deliver more than a service. Take the time. Hold the hand. Care for the patient.

Dr. Phillips is a family physician in Seattle where he practices, teaches and does research. In 1999 he was honored as the Family Physician of the Year in Washington state. He is also a member of the Family Practice Management Board of Editors.

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